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Mumblo, Helen Mary ,”1 NEW YORK STATE DEPARTMENTOF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Helen Mary Mumblo Female Date of Death Age If Veteran of U.S.Armed Forces, 05/04/2021 61 Years War or Dates ▪ Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death ©Natural Cause Accident ❑Homicide El Suicide �Undetermined ❑Pending ILI 0 Circumstances Investigation UJI Medical Certifier Name Title O Marcille Labban MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 202 11 Burial Date Cemetery,Crematory or Facility Name 05/06/2021 Pine View Crematorium ElEntombment Address 0 Cremation Queensbury Town,New York El Donation Z Removal Date Place Removed and/or and/or Held N Hold Address 0 Date Point of Cl) Li Transportation p by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,N+w York 12839 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 5 Address CC W • Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/06/2021 Registrar of Vital Statistics cR96ertAncirew Curtis(ECectronicalTy Signed) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition Y]')I 7i Place of DispositionZtO ,, ^. 2 address) W (section) /](lot number) c (grave number) Q //ql O Name of Sexton or Person in Charge of P ises Z (pleaseiprint) WSignature �� Title � " g / DOH-1555 07/18)p 1 of 2 l Public Health Law Sec. 4145(2b) -- Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#